Clinical Pharmacy Prior Authorization, Notification and Medical Necessity Requirements - Commercial

Abilify MyCite (aripiprazole tablet with sensor) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Absorica (isotretinoin), Absorica LD (isotretinoin micronized), isotretinoin 25 mg and 35 mg (generic Absorica) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Actemra® (tocilizumab) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Actemra® (tocilizumab) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Actimmune® (interferon gamma-1b) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Adalimumab - Abrilada (adalimumab-afzb), Adalimumab-adaz (unbranded Hyrimoz), Adalimumab-fkjp (unbranded Hulio)*, Amjevita™ (adalimumab-atto), Cyltezo® (adalimumab-adbm), Hadlima™ (adalimumab-bwwd), Hulio® (adalimumab-fkjp), Humira® (adalimumab), Hyrimoz® (adalimumab-adaz), Idacio (adalimumab-aacf), Yuflyma (adalimumab-aaty), and Yusimry (adalimumab-aqvh) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Adalimumab - Abrilada (adalimumab-afzb), Adalimumab-adaz (unbranded Hyrimoz), Adalimumab-fkjp (unbranded Hulio), Amjevita™ (adalimumab-atto), Cyltezo® (adalimumab-adbm), Hadlima™ (adalimumab-bwwd), Hulio® (adalimumab-fkjp)*, Humira® (adalimumab), Hyrimoz® (adalimumab-adaz), Idacio (adalimumab-aacf), Yuflyma (adalimumab-aaty), Yusimry (adalimumab-aqvh) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 07.19.2023

Adbry™ (tralokinumab-ldrm) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Adbry™ (tralokinumab-ldrm) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Addyi™ (flibanserin) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Adynovate® (antihemophilic factor [recombinant], pegylated)- Prior Authorizatin/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Afinitor (everolimus) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Afrezza® (insulin human) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Afstyla® (antihemophilic factor [recombinant], single chain) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Afstyla® (antihemophilic factor [recombinant], single chain) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Akeega™ (niraparib and abiraterone acetate) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Aklief® (trifarotene) cream - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Albenza (albendazole) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Albuterol tablets - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Alecensa® (alectinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Altuviiio™ [antihemophilic factor (recombinant), Fc-VWF-XTEN fusion protein-ehtl] - Prior Authorization/Medical Necessity - UnitedHealth Commercial Plans

Last Published 11.01.2023

Altuviiio™ [antihemophilic factor (recombinant), Fc-VWF-XTEN fusion protein-ehtl] - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Alunbrig® (brigatinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Amlodipine/valsartan/hydrochlorothiazide (generic Exforge HCT) - Prior Authorization/Non-Formulary - UnitedHealthcare Commercial Plans

Last Published 02.05.2024

Ampyra® (dalfampridine) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Anticonvulsants - Aptiom® (eslicarbazepine acetate), Banzel® (rufinamide), Briviact® (brivaracetam), Diacomit® (stiripentol), Epidiolex® (cannabidiol), Fintepla® (fenfluramine), Fycompa® (perampanel), Nayzilam® (midazolam), Onfi® (clobazam), Sabril® (vigabatrin), Sympazan® (clobazam), Valtoco® (diazepam), Xcopri® (cenobamate), Ztalmy® (ganaxolone) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Apokyn® (apomorphine) injection - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Apokyn® (apomorphine) injection - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Arcalyst® (rilonacept) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Arikayce® (amikacin liposome inhalation suspension) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Arikayce® (amikacin liposome inhalation suspension) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Augtyro™ (repotrectinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Austedo® (deutetrabenazine) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Austedo® (deutetrabenazine), Austedo® XR (deutetrabenazine) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Ayvakit™ (avapritinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Balversa® (erdafitinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Benlysta® (belimumab) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Benznidazole - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Berinert® (C1 esterase inhibitor [human]) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Berinert® (C1 esterase inhibitor, human) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Besremi® (ropeginterferon alfa-2b-njft) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Bethkis®, Kitabis® Pak, TOBI™ Nebulizer Solution and TOBI® Podhaler™, tobramycin solution for inhalation - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.12.2024

Bonjesta® (doxylamine/pyridoxine extended-release) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Bosulif® (bosutinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Braftovi® (encorafenib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Breast Cancer Prevention Zero Dollar Cost Share - generic tamoxifen (applies to 20 mg dose only), generic raloxifene, generic aromatase inhibitors (anastrozole, letrozole, or exemestane) - Prior Authorization - UnitedHealthcare Commercial Plans

Last Published 04.01.2023

Brexafemme® (ibrexafungerp) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Bronchitol® (mannitol) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Brukinsa® (zanubrutinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Buphenyl®(sodium phenylbutyrate), Olpruva™ (sodium phenylbutyrate), Pheburane® (sodium phenylbutyrate), sodium phenylbutyrate - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Buprenorphine Products - Belbuca (buprenorphine hydrochloride film) and Butrans (buprenorphine patch, extended-release) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Buprenorphine/Naloxone Products - Bunavail and Suboxone (Brand Only) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.01.2023

Bylvay (odevixibat) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Bylvay™ (odevixibat) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Cablivi® (caplacizumab-yhdp) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Cabometyx® (cabozantinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Calquence® (acalabrutinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Camzyos® (mavacamten) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Camzyos® (mavacamten) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Caplyta® (lumateperone) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Caplyta® (lumateperone) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Caprelsa® (vandetanib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Carbaglu® (carglumic acid) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Cardiovascular Disease Prevention Prior Authorization - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Cayston® (aztreonam for inhalation solution) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Cerdelga® (eliglustat) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Cetrotide® (cetrorelix acetate) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

CGRP Receptor Antagonists - Aimovig (erenumab), Ajovy (fremanezumab), Emgality (galcanezumab) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

CGRP Receptor Antagonists - Aimovig (erenumab), Ajovy (fremanezumab), Emgality (galcanezumab) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Cholbam (cholic acid) - Prior Authorization/Notification - UnitedHealthcare Comemercial Plans

Last Published 08.01.2023

Cibinqo™ (abrocitinib) tablets - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Cibinqo™ (abrocitinib) tablets - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Cimzia® (certolizumab) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Cimzia® (certolizumab) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Cinryze® (C1 esterase inhibitor, human) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Cinryze® (C1 esterase inhibitor, human) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

CNS Depressants - Lumryz™ (sodium oxybate), sodium oxybate [Xyrem authorized generic (manufactured by Amneal)], sodium oxybate [Xyrem authorized generic (manufactured by Hikma)], Xyrem® (sodium oxybate), Xywav™ (calcium, magnesium, potassium, and sodium oxybates) - Pior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

CNS Depressants - Lumryz™ (sodium oxybate), sodium oxybate [Xyrem authorized generic (manufactured by Amneal)], sodium oxybate [Xyrem authorized generic (manufactured by Hikma)], Xyrem® (sodium oxybate), Xywav™ (calcium, magnesium, potassium, and sodium oxybates) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Cometriq® (cabozantinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Compounds and Bulk Powders - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Constipation Agents - Amitiza® (lubiprostone), Ibsrela® (tenapanor), Linzess® (linaclotide), Motegrity (prucalopride), Movantik®(naloxegol), Symproic (naldemedine), Trulance (plecanatide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Continuous glucose monitors, sensors and transmitters (all brands) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Continuous Glucose Monitors, sensors and transmitters (all brands) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Contraceptive Medications - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

COPD - Lonhala Magnair® (glycopyrrolate inhalation solution), Yupelri® (revefenacin inhalation solution) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Copiktra® (duvelisib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Corlanor® (ivabradine) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Corlanor® (ivabradine) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Cosentyx®(secukinumab) prefilled syringe or Sensoready pen - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Cosentyx™ (secukinumab) prefilled syringe or Sensoready pen - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Cotellic® (cobimetinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Cuvrior™ (trientine tetrahydrochloride) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Cuvrior™ (trientine tetrahydrochloride) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Cystaran® (cysteamine) ophthalmic solution, Cystadrops® (cysteamine) ophthalmic solution - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Daliresp® (roflumilast) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Daraprim® (pyrimethamine) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Daurismo™ (glasdegib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Daybue™ (trofinetide) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Daybue™ (trofinetide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Descovy® (emtricitabine/tenofovir alafenamide) - Colorado - Prior Authorization/Medical Necessity - UnitedHealthcare Commerical Plans

Last Published 12.21.2023

Descovy® (emtricitabine/tenofovir alafenamide) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Devices - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Diabetes Medications – GLP-1 & Dual GIP/GLP-1 Receptor Agonists - Bydureon BCise (exenatide extended-release), Byetta (exenatide), Mounjaro (tirzepatide), Ozempic (semaglutide), Rybelsus (semaglutide), Trulicity (dulaglutide), Victoza (liraglutide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 05.01.2024

Diabetic Meters and Test Strips - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Diclegis® (doxylamine/pyridoxine delayed-release) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Digital Applications - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Dojolvi® (triheptanoin) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Dojolvi® (triheptanoin) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Doptelet® (avatrombopag) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Doxepin cream - Prudoxin® (doxepin), Zonalon® (doxepin) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Doxepin cream - Prudoxin® (doxepin), Zonalon® (doxepin) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Dry Eye Disease - Cequa™ (cyclosporine 0.09% ophthalmic solution), Miebo™ (perfluorohexyloctane), Restasis® (cyclosporine 0.05% ophthalmic emulsion), Restasis MultiDose™ (cyclosporine 0.05% ophthalmic emulsion), Tyrvaya™ (varenicline nasal spray), Vevye™ (cyclosporine 0.1%), Xiidra® (lifitegrast 5% ophthalmic solution) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Dry Eye Disease - Cequa™ (cyclosporine 0.09% ophthalmic solution), Miebo™ (perfluorohexyloctane), Restasis® MultiDose™ (cyclosporine 0.05% ophthalmic emulsion), Tyrvaya™ (varenicline nasal spray), Vevye™ (cyclosporine 0.1%) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Duopa (carbidopa/levodopa) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Dupixent® (dupilumab) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Dupixent® (dupilumab) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Egrifta SV™ (tesamorelin for injection) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Eloctate® [antihemophilic factor (recombinant), Fc fusion protein] - Prior Authorizatin/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Eloctate® [antihemophilic factor (recombinant), Fc fusion protein] - Prior Authorization/Medical Necessity - UnitedHealth Commercial Plans

Last Published 12.28.2023

Emflaza® (deflazacort) - PA-Notification - UnitedHealthcare Commerical Plans

Last Published 12.21.2023

Emflaza® (deflazacort) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Empaveli® (pegcetacoplan) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Empaveli® (pegcetacoplan) - Prior Authorization/Notification - UniteedHealthcare Commercial Plans

Last Published 04.19.2024

Emverm (mebendazole) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Enbrel® (etanercept) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Enbrel® (etanercept) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Endari® (L-glutamine Powder for Solution) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Enspryng™ (satralizumab) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Enspryng™ (satralizumab) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Entresto (valsartan-sacubitril) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Entresto® (valsartan-sacubitril) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Envarsus XR™ (tacrolimus extended-release tablets) - Prior Authorization/Non-Formulary - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Epclusa (sofosbuvir/velpatasvir) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Epclusa® (sofosbuvir/velpatasvir) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Epsolay (benzoyl peroxide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Erivedge® (vismodegib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Erleada® (apalutamide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Esperoct® (antihemophilic factor [recombinant], glycopegylated-exei) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Esperoct®[antihemophilic factor (recombinant), glycopegylated-exei] - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Evrysdi (risdiplam) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Evrysdi®(risdiplam) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Exalgo (hydromorphone extended-release) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.15.2022

Exkivity™ (mobocertinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Fabhalta® (iptacopan) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Fabhalta® (iptacopan) - Prior Authorization/Notification - UniteedHealthcare Commercial Plans

Last Published 04.19.2024

Fasenra® (benralizumab) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Fasenra™ (benralizumab) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Fentanyl - Actiq (brand only) (fentanyl transmucosal lozenge), Fentora (fentanyl buccal tablet), Lazanda (fentanyl nasal spray), Subsys (fentanyl sublingual spray), and fentanyl citrate bulk powder - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Fentanyl - Actiq (fentanyl transmucosal lozenge), Fentora (fentanyl buccal tablet), Lazanda (fentanyl nasal spray), Subsys (fentanyl sublingual spray), and fentanyl citrate - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Filspari™ (sparsentan) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Filsuvez® (birch triterpenes) topical gel - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Filsuvez® (birch triterpenes) topical gel - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Firazyr® (icatibant), icatibant, Sajazir™ (icatibant) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Firazyr® (icatibant), icatibant, Sajazir™ (icatibant) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Firdapse® (amifampridine) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Firdapse® (amifampridine) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Fluticasone propionate HFA - Non-Formulary - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Follicle-stimulating Hormone (FSH) - Follistim® AQ (follitropin beta), Gonal-f™ (follitropin alfa), Gonal-f™ RFF (follitropin alfa) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

FollistimAQ (follitropin beta), Gonal-f™ (follitropin alfa), Gonal-f™ RFF (follitropin alfa), Menopur® (menotropins) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.05.2024

Forteo® (teriparatide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Fotivda® (tivozanib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Fruzaqla™ (fruquintinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Furoscix® (furosemide injection) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Furoscix® (furosemide injection) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Fuzeon® (enfuvirtide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Galafold® (migalastat) (migalastat) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Gattex® (teduglutide [rDNA origin]) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Gavreto™ (pralsetinib) - Prior Authorizatin/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Gilotrif® (afatinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Gleevec® (imatinib mesylate) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Glumetza® (metformin extended-release modified release, brand and generic) and metformin osmotic extended-release (generic Fortamet®) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Gonadotropin-releasing hormone (GnRH) Antagonists - Cetrotide® (cetrorelix acetate) and ganirelix acetate - Prior Authorizatin/Notification - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Gonococcal Ophthalmia Neonatorum (GON) Prevention Zero Dollar Cost Share – erythromycin 0.5% ophthalmic ointment - Prior Authorization/Regulatory - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Haegarda® (C1 esterase inhibitor Subcutaneous, human) - Prior Authorization/Notification - UnitedHealthcare Commercial Plan

Last Published 06.01.2024

Haegarda® (C1 esterase inhibitor, human) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Harvoni® (ledipasvir/sofosbuvir) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Harvoni® (ledipasvir/sofosbuvir) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Hemlibra® (emicizumab-kxwh) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Hemlibra® (emicizumab-kxwh) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Hetlioz®, Hetlioz LQ™ (tasimelteon) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Hetlioz®, Hetlioz LQ™ (tasimelteon) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

HIV Medications with Pre-exposure Prophylaxis (PrEP) Use Zero Dollar Cost Share - California - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.27.2023

human chorionic gonadotropin (hCG) - Novarel® (chorionic gonadotropin), Ovidrel® (choriogonadotropin alfa), and Pregnyl® (chorionic gonadotropin) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Human Growth Hormone - Somatropin (Genotropin®, Humatrope®, Norditropin®, NordiFlex®, Nutropin AQ NuSpin®, Omnitrope®, Saizen®, Zomacton®, Zorbtive®, and Serostim®), Skytrofa™, (lonapegsomatropin-tcgd), Sogroya®*(somapacitan-beco), Ngenla™ (somatrogon-ghla). Growth Stimulating Products - Mecasermin (Increlex®) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 03.15.2024

Human Growth Hormone - Somatropin (Genotropin®, Humatrope®, Norditropin®, NordiFlex®, Nutropin AQ® NuSpin®, Omnitrope®, Saizen®, Zomacton®, Zorbtive®, and Serostim®), Skytrofa™ (lonapegsomatropin-tcgd), Sogroya® (somapacitan-beco), Ngenla™ (somatrogon-ghla). Growth Stimulating Products - Mecasermin (Increlex®) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 03.15.2024

Hycamtin® (topotecan hydrochloride) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Hyftor® (sirolimus topical gel) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Ibrance® (palbociclib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Ibsrela® (tenapanor) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Iclusig® (ponatinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Idhifa® (enasidenib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Idiopathic Pulmonary Fibrosis - Esbriet® (pirfenidone) and Ofev® (nintedanib) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Idiopathic Pulmonary Fibrosis - Esbriet® (pirfenidone) and Ofev® (nintedanib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 05.31.2024

Ilumya™ (tildrakizumab-asmn) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Ilumya™ (tildrakizumab-asmn) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Imbruvica® (ibrutinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Impavido (miltefosine) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Inbrija® (levodopa inhalation powder) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Inbrija® (levodopa inhalation powder) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Ingrezza® (valbenazine) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Ingrezza® (valbenazine) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Inlyta® (axitinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Inqovi® (decitabine and cedazuridine) tablet - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Inrebic® (fedratinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Interim New Product Coverage Criteria - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Intrarosa (prasterone) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Invokana® (canagliflozin) - Non-Formulary - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Iressa® (gefitinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Iron Chelators - Exjade® (deferasirox), Jadenu® (deferasirox), and Ferriprox® (deferiprone) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Isturisa® (osilodrostat) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Iwilfin™ (eflornithine) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Ixinity [coagulation factor IX (recombinant)] - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Jakafi® (ruxolitinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Javygtor™ (sapropterin dihydrochloride) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Jaypirca® (pirtobrutinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Jesduvroq® (daprodustat) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Jesduvroq® (daprodustat) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Jivi® (antihemophilic factor [recombinant], PEGylated-aucl) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Jivi® (antihemophilic factor [recombinant], PEGylated-aucl) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Joenja® (leniolisib) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Joenja® (leniolisib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Jublia® (efinaconazole) and Kerydin® (tavaborole) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.05.2024

Juxtapid® (lomitapide) - Prior Authorization - Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Juxtapid® (lomitapide) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Jynarque (tolvaptan) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Kalydeco® (ivacaftor) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Kalydeco® (ivacaftor) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Kerendia® (finerenone) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Kerendia® (finerenone) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Keveyis® (dichlorphenamide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Kevzara® (sarilumab) Injection - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Kevzara® (sarilumab) Injection - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Kineret® (anakinra) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Kisqali® (ribociclib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Kisqali® Femara® Co-Pack (ribociclib/letrozole) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Korlym® (mifepristone) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Koselugo™ (selumetinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Krazati™ (adagrasib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Kuvan® (sapropterin dihydrochloride) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Lampit® (nifurtimox) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Lenvima® (lenvatinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Leuprolide acetate (bulk powder, 1 mg/0.2 mL injection) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Levemir (insulin detemir) - Prior Authorizatin/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Lidocaine Patch (Lidoderm®) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Litfulo™ (ritlecitinib) Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 01.14.2024

Litfulo™ (ritlecitinib) Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 01.14.2024

Lithobid® (brand only) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Livmarli™ (maralixibat) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.02.2023

Livmarli™ (maralixibat) Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.31.2023

Livtencity (maribavir) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Lokelma (sodium zirconium cyclosilicate) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Long-Acting Opioid Pain Medications - fentanyl transdermal patch (generic Duragesic®) 12, 25, 50, 75, 100 mcg/hr, fentanyl transdermal patch 37.5, 62.5, 87.5 mcg/hr, hydrocodone extended-release capsules (generic ZohydroTM ER), hydrocodone extended-release tablets (generic HysinglaTM ER), hydromorphone extended-release (generic Exalgo®), Hysingla ER, methadone, morphine sulfate controlled-release capsules (generic Avinza®), morphine sulfate controlled-release tablets (generic MS Contin®), morphine sulfate sustained-release capsules (generic Kadian®), MS Contin, Nucynta® ER (tapentadol extended-release), oxycodone controlled-release (authorized generic for OxyContin®), OxyContin^, oxymorphone extended-release (generic Opana® ER), Xtampza® ER (oxycodone extended-release) – Prior Authorization/Medical Necessity – UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Lonsurf® (trifluridine/tipiracil) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Lorbrena® (lorlatinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Lotronex® (alosetron) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Lucemyra® (lofexidine) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Lumakras™ (sotorasib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Lupkynis (voclosporin) - Prior Authoization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Lupkynis (voclosporin) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Lybalvi™ (olanzapine/samidorphan) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Lynparza® (olaparib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Lytgobi® (futibatinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Mavenclad® (cladribine) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Mavyret (glecaprevir/pibrentasvir) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Mavyret™ (glecaprevir/pibrentasvir) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Mekinist® (trametinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Mektovi® (binimetinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Menopur® (menotropins) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Methyldopa - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Mifeprex (mifepristone) - Benefit Determination - UnitedHealthcare Commercial Plans

Last Published 05.31.2024

Migraine - Dihyroergotamine nasal spray (Migranal®), Ergomar® (ergotamine), Trudhesa® (dihydroergotamine nasal spray) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Migraine - Nurtec® ODT (rimegepant), Qulipta™ (atogepant), Ubrelvy™ (ubrogepant), Zavzpret™ (zavegepant) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Migraine - Nurtec® ODT (rimegepant), Qulipta™ (atogepant), Ubrelvy™ (ubrogepant), Zavzpret™ (zavegepant) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 10.04.2023

minocycline extended-release tablet (generic Solodyn™), Minolira™ (minocycline extended-release tablet ), Solodyn (minocycline extended-release tablet), Ximino® (minocycline extended-release capsule) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Mirvaso (brimonidine gel) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Motegrity (prucalopride) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Movantik (naloxegol) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Mulpleta® (lusutrombopag) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Multaq® (dronedarone) - Prior Authorization/Notification - UnitedHealthcare Commrcial Plans

Last Published 12.21.2023

Multiple Sclerosis - Aubagio® (teriflunomide), Avonex® (interferon β-1a), Bafiertam™ (monomethyl fumarate), Betaseron® (interferon β-1b), Copaxone® (glatiramer acetate), dimethyl fumarate, Extavia® (interferon β-1b), fingolimod, Gilenya® (fingolimod), Glatopa™ (glatiramer acetate), glatiramer acetate, Kesimpta (ofatumumab), Mayzent (siponimod)®, Plegridy™ (peginterferon β-1a), Ponvory™ (Ponesimod), Rebif® (interferon β-1a), Tascenso ODT™ (fingolimod), Tecfidera™ (dimethyl fumarate), teriflunomide, Vumerity™ (diroximel fumarate) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Multisource Brand/Modified Release Anticonvulsants – Banzel®, Depakote®, Depakote ER®, Felbatol®, Keppra®, Keppra XR®, Lamictal, Lamictal XR, Lamictal ODT (brand and generic), Lyrica®, Motpoly XR, Mysoline®, Neurontin®, Onfi®, Sabril®, Topamax®, Trileptal®, Vimpat®, Zonegran®- Prior Athorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Myalept® (metreleptin) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Myalept® (metreleptin) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Mycapssa® (octreotide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Mycapssa™ (octreotide) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Mytesi™ (crofelemer) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Natpara® (parathyroid hormone analog) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Natpara® (parathyroid hormone analog) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Nerlynx® (neratinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

New and Therapeutic Equivalent Medications - Excluded Drug - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

New and Therapeutic Equivalent Medications - Prior Authorization - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Nexavar® (sorafenib tosylate) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Nexletol® (bempedoic acid), Nexlizet ® (bempedoic acid/ezetimibe) - Pruir Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Ninlaro® (ixazomib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Nityr® (nitisinone) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Nocdurna® (desmopressin acetate) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Non-Solid Oral and Suppository Dosage Forms - Alkindi® Sprinkle (hydrocortisone), Aspruzyo Sprinkle™ (ranolazine), Atorvaliq® (atorvastatin), Carafate® (sucralfate) suspension, Carospir® (spironolactone), chlorpromazine oral solution, Epaned® (enalapril), Eprontia® (topiramate), Ermeza™ (levothyroxine), Exservan™ (riluzole), Ezallor Sprinkle™ (rosuvastatin), Fleqsuvy® (baclofen), Flolipid (simvastatin), Indocin® (indomethacin) suspension, Indocin (indomethacin) suppository, Katerzia® (amlodipine), Lyvispah® (baclofen), Meloxicam (meloxicam) suspension, Naprosyn® (naproxen) suspension, Nexium® for suspension (esomeprazole), Norliqva® (amlodipine), Ozobax® (baclofen), Ozobax DS (baclofen), Pradaxa® (dabigatran) oral pellets, Prevacid® SoluTab™ (lansoprazole), Prograf® Granules (tacrolimus), Qbrelis® (lisinopril), Qdolo™ (tramadol), Renvela® (sevelamer carbonate) powder for suspension, Sotylize® (sotalol), Sympazan (clobazam)®, Syndros® (dronabinol), Tiglutik® (riluzole), Tirosint®-Sol (levothyroxine), Valsartan oral solution, Xatmep® (methotrexate), Xelstrym™ (dextroamphetamine), Zegerid® for suspension (omeprazole and sodium bicarbonate), Zonisade® (zonisamide) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Northera (droxidopa) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Nourianz (istradefylline) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Nubeqa® (darolutamide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Nucala® (mepolizumab) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Nucala® (mepolizumab) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Nuedexta (dextromethorphan/quinidine) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Nuedexta (dextromethorphan/quinidine) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Nuplazid® (pimavanserin) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Ocaliva (obeticholic acid) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Ocaliva (obeticholic acid) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Odomzo® (sonidegib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Ogsiveo™ (nirogacestat) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Ojjaara™ (momelotinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Olumiant® (baricitinib) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Olumiant® (baricitinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Omnipod 5 - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.28.2023

Omnipod® 5 - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Omvoh™ (mirikizumab-mrkz) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Omvoh™ (mirikizumab-mrkz) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Onureg® (azacitidine) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Opfolda™ (miglustat) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Ophthalmic Agents - Qlosi (pilocarpine)™ 0.4% ophthalmic solution, Vuity® (pilocarpine) 1.25% ophthalmic solution Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Opioid Supply Limits - Greater than 34 Day Supply for Opioids at Retail

Last Published 06.02.2024

Opioid-containing cough medicines - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Opzelura™ (ruxolitinib) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.05.2024

Opzelura™ (ruxolitinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Oral chemotherapeutic agents - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Orencia® (abatacept) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Orencia® (abatacept) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Orfadin® (nitisinone) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Orgovyx™ (relugolix) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Oriahnn® (elagolix and estradiol/norethindrone), MyFembree® (relugolix and estradiol hemihydrate/norethindrone) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Orilissa® (elagolix) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Orkambi™ (lumacaftor/ivacaftor) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Orkambi™ (lumacaftor/ivacaftor) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Orladeyo® (berotralstat) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Orladeyo® (berotralstat) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Orserdu™ (elacestrant) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Osphena® (ospemifene) - Prior Authorization/Notification - UniteHealthcare Commercial Plans

Last Published 06.01.2024

Otezla® (apremilast) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Oxbryta™ (voxelotor) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Oxbryta™ (voxelotor) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Oxervate® (cenegermin-bkbj) ophthalmic solution - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Oxervate® (cenegermin-bkbj) ophthalmic solution - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

PAH Agents - Adcirca® (tadalafil), Adempas® (riociguat), Alyq™ (tadalafil), Letairis® (ambrisentan), Liqrev® (sildenafil) oral suspension, Opsumit® (macitentan), Orenitram™ (treprostinil), Revatio® (sildenafil citrate) oral powder for suspension, Tadliq® (tadalafil) oral suspension, Tracleer® (bosentan), Tyvaso® (treprostinil), Tyvaso DPI™ (treprostinil), Uptravi® (selexipag), Ventavis® (iloprost) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

PAH Agents - Adcirca® (tadalafil), Adempas® (riociguat), Alyq™ (tadalafil), Letairis® (ambrisentan), Liqrev® (sildenafil) oral suspension, Opsumit® (macitentan), Orenitram™ (treprostinil), Revatio® (sildenafil citrate) oral powder for suspension, Tadliq® oral suspension (tadalafil), Tracleer® (bosentan), Tyvaso® (treprostinil), Tyvaso DPI™ (treprostinil), Uptravi® (selexipag), Ventavis® (iloprost) - Prior Authorizatin/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp] - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp] - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Palynziq ( pegvaliase-pqpz) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Palynziq™ (pegvaliase-pqpz) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Pemazyre®(pemigatinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Phexxi (lactic acid, citric acid, and potassium bitartrate) vaginal gel - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Piqray® (alpelisib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Pomalyst® (pomalidomide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Praluent® (alirocumab) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Praluent® (alirocumab)- Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Prevymis™ (letermovir) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Procysbi® (cysteamine bitartrate) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Promacta® (eltrombopag) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Pulmozyme® (dornase alfa) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Pyrukynd® (mitapivat) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Pyrukynd® (mitapivat) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Qelbree (viloxazine) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Qinlock™ (ripretinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Radicava ORS® (edaravone) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Radicava ORS® (edaravone)- Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Ravicti® (glycerol phenylbutyrate oral liquid) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Ravicti™ (glycerol phenylbutyrate oral liquid) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Recorlev® (levoketoconazole) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Regranex® (becaplermin gel) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Relistor (methylnaltrexone bromide) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Relyvrio® (sodium phenylbutyrate and taurursodiol) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Relyvrio® (sodium phenylbutyrate and taurursodiol) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Repatha® (evolocumab) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Repatha® (evolocumab) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Repository Corticotropins - Acthar Gel® (Repository corticotropin injection), Purified Cortrophin Gel™ (Repository corticotropin injection USP) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Repository Corticotropins - Acthar Gel® (Repository corticotropin injection), Purified Cortrophin Gel™ (Repository corticotropin injection USP) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Retevmo®(selpercatinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Revlimid® (lenalidomide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Rexulti (brexpiprazole) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Reyvow® (lasmiditan) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Reyvow® (lasmiditan) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Rezdiffra™ (resmetirom) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Rezdiffra™ (resmetirom) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Rezlidhia™ (olutasidenib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Rezurock™ (belumosudil) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Rhofade (oxymetazoline cream) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Rinvoq™ (upadacitinib) extended-release tablets - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Rinvoq™ (upadacitinib) extended-release tablets - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Rozlytrek™ (entrectinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Rubraca® (rucaparib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Ruconest® (C1 esterase inhibitor [recombinant]) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Ruconest® (C1 esterase inhibitor [recombinant]) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Rukobia (fostemsavir) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Rydapt®(midostaurin) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Samsca (tolvaptan) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Sandostatin® (octreotide acetate) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Scemblix® (asciminib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Selzentry® (maraviroc) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Sensipar (cinacalcet) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Short-Acting Opioid Review Criteria for opioid naïve members - UnitedHealthcare Commercial Plans

Last Published 02.05.2024

Signifor® (pasireotide diaspartate) - Prior Authorization/Notification - UnitedHealth Commercial Plans

Last Published 12.21.2023

Siliq (brodalumab) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Siliq™ (brodalumab) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Simponi® (golimumab) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Simponi® (golimumab) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 10.18.2023

Single Source Brand Anticonvulsants – Aptiom® (eslicarbazepine), Briviact® (brivaracetam), Epidiolex® (cannabidiol), Fintepla® (fenfluramine), Fycompa® (perampanel), Xcopri® (cenobamate) and Ztalmy® (ganaxolone) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Skyclarys™ (omaveloxolone) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Skyclarys™ (omaveloxolone) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Skyrizi® (risankizumab-rzaa) injection - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Skyrizi® (risankizumab-rzaa) injection - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Slynd® (drospirenone) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Sohonos™ (palovarotene) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Sohonos™ (palovarotene) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Solaraze (diclofenac 3% gel) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Somavert® (pegvisomant) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Somavert® (pegvisomant) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Sotyktu™ (deucravacitinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Sotyktu™ (deucravacitinib) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Sovaldi® (sofosbuvir) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Sovaldi® (sofosbuvir) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Spravato® (esketamine) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Spravato™ (esketamine) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Sprycel® (dasatinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Stelara™ (ustekinumab) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Stelara™ (ustekinumab) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Stendra (avanafil) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Stivarga® (regorafenib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Strensiq® (asfotase alfa) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Strensiq™ (asfotase alfa) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Stromectol® (ivermectin) oral dosage form - Prior Authorizatin/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Sublingual Immunotherapy (SLIT) - Grastek (Timothy grass pollen allergen extract), Odactra (Dermatophagoides farinae/Dermatophagoides pteronyssinus allergen extract), Oralair (Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens allergen extract), Ragwitek (Short Ragweed Pollen allergen extract) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Sublingual Immunotherapy (SLIT) – Grastek (Timothy grass pollen allergen extract), Odactra (Dermatophagoides farinae/Dermatophagoides pteronyssinus allergen extract), Oralair (Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens allergen extract), Ragwitek (Short Ragweed Pollen allergen extract) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Suboxone - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.22.2024

Sucraid (sacrosidase) oral solution - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Sucraid (sacrosidase) oral solution Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Sunlenca® (lenacapavir) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Sunosi® (solriamfetol) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Sunosi® (solriamfetol) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Sutent® (sunitinib malate) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Symdeko® (tezacaftor/ivacaftor) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Symdeko® (tezacaftor/ivacaftor) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Synribo® (omacetaxine) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Syprine® (trientine hydrochloride), Trientine hydrochloride - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Tabrecta™ (capmatinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Tafinlar® (dabrafenib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Tagrisso™ (osimertinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Takhzyro® (lanadelumab-flyo) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Takhzyro™ (lanadelumab-flyo) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Taltz (ixekizumab) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Taltz® (ixekizumab) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Talzenna® (talazoparib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Tarceva® (erlotinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Tarpeyo® (budesonide delayed-release capsules) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Tasigna® (nilotinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Tasmar® (tolcapone) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Tavalisse®(fostamatinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Tavneos® (avacopan) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Tavneos® (avacopan) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Tazorac® (tazarotene) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Tazverik®(tazemetostat) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Tegsedi® (inotersen) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Tegsedi® (inotersen) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Temodar® (temozolomide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Tepmetko® (tepotinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Testosterone - Androderm®, Androgel®, Fortesta®, Jatenzo®, Natesto®, Kyzatrex™, Testim®, testosterone topical solution (generic Axiron®), testosterone transdermal gel (generic Testim), Tlando™, Vogelxo®, Xyosted® - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Tetrabenazine (Xenazine®) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Tezspire™ (tezepelumab-ekko) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Tezspire™ (tezepelumab-ekko) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Thalomid® (thalidomide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Therapeutic Duplication - Administrative Override - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Tibsovo® (ivosidenib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Tobacco Cessation - Varenicline (generic Chantix®), Nicotrol Inhaler® (nicotine inhalation system), and Nicotrol NS® (nicotine nasal spray) - Prior Authorization/Notification - Healthcare Reform - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Tobacco Cessation – New Jersey Fully Insured Varenicline (generic Chantix®), Nicotrol Inhaler® (nicotine inhalation system), and Nicotrol NS® (nicotine nasal spray) - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Tobacco Cessation – Supply Limit (Therapy Duration) Override – Kentucky Fully Insured - Varenicline (generic Chantix®), Nicotrol Inhaler® (nicotine inhalation system), and Nicotrol NS® (nicotine nasal spray) - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Topical Products - NJ & NY - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Topical Retinoid Products - Altreno® (tretinoin), Arazlo®, (tazarotene), Avita® (tretinoin), Atralin® (tretinoin), Retin-A® (tretinoin) [brand only], Retin-A Micro® (tretinoin microspheres), Differin® (adapalene), Fabior® (tazarotene), Tazorac® (tazarotene), and Aklief® (trifarotene) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Tremfya® (guselkumab) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Tremfya® (guselkumab) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Trikafta® (elexacaftor/tezacaftor/ivacaftor) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Trikafta® (elexacaftor/tezacaftor/ivacaftor) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Trulance® (plecanatide) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Truqap™ (capivasertib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Truseltiq™ (infigratinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 10.01.2021

Tukysa® (tucatinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Turalio® (pexidartinib)- Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Tykerb® (lapatinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Tymlos™ (abaloparatide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Upneeq (oxymetazoline) 0.1% ophthalmic solution - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Valchlor® gel for topical use (mechlorethamine) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Vanflyta® (quizartinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Vascepa® (icosapent ethyl) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Vascepa® (icosapent ethyl) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Vecamyl® (mecamylamine) - Prior Authorization/Notificataion - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Veltassa (patiromer) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Vemlidy® (tenofovir alafenamide) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Venclexta (venetoclax) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Veozah™ (fezolinetant) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Verkazia (cyclosporine 0.1% ophthalmic emulsion) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Verquvo® (vericiguat) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Verquvo® (vericiguat) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Verzenio® (abemaciclib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Viberzi® (eluxadoline) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Viekira Pak (ombitasvir, paritaprevir, and ritonavir tablets) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Viekira Pak™ (ombitasvir, paritaprevir, and ritonavir tablets; dasabuvir tablets) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Vijoice® (alpelisib) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Vijoice® (alpelisib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Vitrakvi® (larotrectinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Vivjoa (oteseconazole) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Vizimpro® (dacomitinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Vonjo (pacritinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Voquezna® (vonoprazan) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Vosevi®(sofosbuvir, velpatasvir, and voxilaprevir) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Vosevi™ (sofosbuvir, velpatasvir, and voxilaprevir) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 11.01.2023

Votrient® (pazopanib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Vowst (fecal microbiota spores, live-brpk) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Vowst (fecal microbiota spores, live-brpk) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Voxzogo™ (vosoritide) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Voxzogo™ (vosoritide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Vtama® (tapinarof) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.05.2024

Vtama® (tapinarof) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Vumerity™ (diroximel fumarate) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Vyleesi™ (bremelanotide) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Vyndaqel® (tafamidis meglumine) and Vyndamax (tafamidis) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Vyndaqel® (tafamidis meglumine) and Vyndamax™ (tafamidis) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Wainua™ (eplontersen) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Wainua™ (eplontersen) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Wakix® (pitolisant) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Wakix® (pitolisant) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Weight Loss – phentermine (all brand products including Adipex-P® and Lomaira™), benzphetamine, Contrave® (naltrexone HCl and bupropion HCl, diethylpropion, Imcivree® (setmelanotide), phendimetrazine, orlistat (Xenical®), Qsymia® (phentermine and topiramate extended-release), Saxenda® (liraglutide), Wegovy® (semaglutide) and Zepbound™ (tirzepatide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Welireg™ (belzutifan) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Winlevi (clascoterone) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Xalkori® (crizotinib) - Non-Formulary - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Xalkori® (crizotinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Xdemvy™ (lotilaner) ophthalmic solution 0.25% - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Xeljanz®/Xeljanz® XR/Xeljanz® Oral Solution (tofacitinib) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Xeljanz®/Xeljanz® XR/Xeljanz® Oral Solution (tofacitinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Xermelo (telotristat ethyl) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Xifaxan (rifaximin) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 09.29.2023

Xolair® (omalizumab) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Xolair®(omalizumab) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Xospata®(gilteritinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Xphozah® (tenapanor) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Xphozah® (tenapanor) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Xpovio™ (selinexor) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Xtandi® (enzalutamide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Xuriden® (uridine triacetate) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Xyntha (antihemophilic factor [recombinant]) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 12.28.2023

Yonsa® (abiraterone acetate) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Zejula™ (niraparib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.24.2023

Zelboraf® (vemurafenib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Zepatier® (elbasvir/grazoprevir) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Zepatier® (elbasvir/grazoprevir) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Zeposia® (ozanimod) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 06.30.2023

Zeposia® (ozanimod) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 03.01.2024

Zilbrysq® (zilucoplan) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Zilbrysq® (zilucoplan) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Zilxi® (minocycline) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Zokinvy™ (lonafarnib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 06.01.2024

Zolinza® (vorinostat) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 12.21.2023

Zoryve® (roflumilast) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Zoryve® (roflumilast) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.01.2024

Ztalmy (ganaxolone) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Last Published 02.01.2023

ZTLido™ - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Zurzuvae™ (zuranolone) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 02.01.2024

Zydelig® (idelalisib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

Zykadia® (ceritinib) - Non-Formulary - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Zykadia® (ceritinib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 04.19.2024

Zytiga® (abiraterone acetate) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Last Published 08.01.2023

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Clinical Pharmacy Prior Authorization, Notification and Medical Necessity Requirements - Commercial